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QCDR data entry - CPRA Hospital - Copy 2
Provider Name:
*
Provider Name who personally performed case.
First
Last
Facility:
Middle Park Medical Center
Facility Type:
*
Type of anesthesia that was administered during case.
Hospital
Date of Service:
*
Date of service case occurred.
MM
DD
YYYY
Patient Name:
*
Patient name as it appears on patient sticker.
First
Last
Date of Birth:
*
Patients date of birth.
MM
DD
YYYY
Gender
Female
Male
Anesthesia Type:
General
MAC / IV Sedation
MAC / Block combo
Spinal
Axillary Block
ASA Physical Status
ASA 1
ASA 2
ASA 3
ASA 4
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin
*
21
Yes
No
N/A
Documentation of Current Medications in the Medical Record
*
130
Yes
No
N/A
Sleep Apnea: Assessment of Sleep Symptoms
*
276
Yes
No
N/A
Patient - Centered Surgical Risk Assessment and Communication
358
Yes
No
N/A
Anesthesiology Smoking Abstinence
*
404
Yes
No
N/A
Perioperative Temperature Management
*
424
Yes
No
N/A
Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)
*
426
Yes
No
N/A
Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy
*
430
Yes
No
N/A
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
*
44
Yes
No
N/A
Medication Reconciliation Post-Discharge
*
46
Yes
No
N/A
Care Plan
*
47
Yes
No
N/A
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
*
76
Yes
No
N/A
Pain Assessment and Follow-Up
*
131
Yes
No
N/A
Coronary Artery Bypass Graft (CABG): Stroke
*
166
Yes
No
N/A
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
*
352
Yes
No
N/A
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
*
427
Yes
No
N/A
Case delayed reason
Anesthesia delay
Surgeon tardy
Patient tardy
Medical reason
OR delay
Exceeded allotted time in prior case
Facility staff delay
Lab delay
Equipment delay
Case cancelled reason
Anesthesia cancelled - medical necessity
Surgeon cancelled
Facility cancelled
Patient no show
Difficult Airway
Yes
No
Unexpected transfer to Hospital
Precautionary - patient alert
Emergency - patient unresponsive
Adverse Outcome
Yes
No